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Chemotherapy in Advanced Gastric Cancer: A Systematic Review and Meta-Analysis Based on Aggregate Data
Open accessAbstract
Purpose: This systematic review and meta-analysis were performed to assess the efficacy and tolerability of chemotherapy in patients with advanced gastric cancer. Methods: Randomized phase II and III clinical trials on first-line chemotherapy in advanced gastric cancer were identified by electronic searches of Medline, Embase, the Cochrane Controlled Trials Register, and Cancerlit; hand searches of relevant abstract books and reference lists; and contact to experts. Meta-analysis was performed using the fixed-effect model. Overall survival, reported as hazard ratio (HR) with 95% CI, was the primary outcome measure. Results: Analysis of chemotherapy versus best supportive care (HR = 0.39; 95% CI, 0.28 to 0.52) and combination versus single agent, mainly fluorouracil (FU) -based chemotherapy (HR = 0.83; 95% CI = 0.74 to 0.93) showed significant overall survival benefits in favor of chemotherapy and combination chemotherapy, respectively. In addition, comparisons of FU/cisplatin-containing regimens with versus without anthracyclines (HR = 0.77; 95% CI, 0.62 to 0.95) and FU/anthracycline-containing combinations with versus without cisplatin (HR = 0.83; 95% CI, 0.76 to 0.91) both demonstrated a significant survival benefit for the three-drug combination. Comparing irinotecan-containing versus nonirinotecan-containing combinations (mainly FU/cisplatin) resulted in a nonsignificant survival benefit in favor of the irinotecan-containing regimens (HR = 0.88; 95% CI, 0.73 to 1.06), but they have never been compared against a three-drug combination. Conclusion: Best survival results are achieved with three-drug regimens containing FU, an anthracycline, and cisplatin. Among these, regimens including FU as bolus exhibit a higher rate of toxic deaths than regimens using a continuous infusion of FU, such as epirubicin, cisplatin, and continuous-infusion FU.
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“The pyrimidine analogue 5-fluorouracil (5-FU) is a synthetic analogue of uracil that inhibits thymidylate synthase, limiting the availability of thymidine nucleotides for DNA synthesis (Figure 1b, Figure 2c). 5-FU and the related 5-FU-prodrug capecitabine remain widely used chemotherapies today and are an important treatment for gastrointestinal cancers (Heidelberger et al., 1957; Wagner et al., 2”
From Targeting Metabolism for Cancer Therapy (2017) · cites this paper as Wagner et al., 2006
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“Treatment with epirubicin, cisplatin, and continuous infusion 5-FU (ECF) has shown survival advantage compared with various nonanthracycline-containing fluoropyrimidine combinations.(5,6,8,10) In phase II studies, the ECF regimen resulted in response rates greater than 50%, with moderate toxicity.”
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Targeted therapy for advanced gastric cancer: A review of current status and future prospects
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“Chemotherapy is an important treatment option for gastric cancer patients besides surgical resection.(2) However, chemotherapy has two main issues that affect the treatment of gastric cancer patients: the resistance of tumor tissue against chemotherapeutic drugs and the toxicity of these drugs to normal tissue.”
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NFATc3 mediates the sensitivity of gastric cancer cells to arsenic sulfide
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“However, the mainstay therapy for the advanced stage GC is systemic chemotherapy, with the 5-year overall survival less than 20% [3].”
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“93) demonstrated significant overall survival (OS) results in favor of chemotherapy and combination chemotherapy.(4,5) Several chemotherapeutic drugs, including 5-FU, mitomycin C, nitrosoureas, and doxorubicin have evidenced some level of efficacy against advanced gastric cancer.”
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“Overview of the market A need for better treatment The most commonly used regimens to treat gastric cancer are a fluoropyrimidine (capecitabine or 5‐fluorouracil [5‐FU]) and a platinum agent (cisplatin or oxaliplatin) alone or in combination with an anthracy‐ cline [4–6,103].”
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“4 Trastuzumab Chemotherapy improved survival compared to BSC in patients with advanced gastric cancer (GC) and combination chemotherapy was superior to monotherapy [41].”
BackgroundSeom guidelines for the treatment of gastric cancer 2015
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“Several randomized studies and a meta-analysis [47], comparing palliative CT with the best supportive care (BSC), have demonstrated that CT increases median overall survival and improves the quality of life of patients with advanced gastric cancer [I,A].”
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“Improvements in the treatment of gastric cancer, including combination chemotherapy, have resulted in improved overall survival versus single-agent chemotherapy alone.(6)”
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“A meta-analysis that compared systemic single therapy with combination treatment found that combination treatment was associated with a significantly greater response rate [19].”
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“J Natl Compr Canc Netw 2016;14(11):1379–1388”
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“[6] including phase 2 and 3 studies for the primary treatment of metastatic gastric cancer, both monotherapy and combined chemotherapy were found to be superior to BCS alone.”
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Prognostic Significance of Non-curative Gastrectomy for Incurable Gastric Carcinoma
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Eastern Canadian Colorectal Cancer Consensus Conference: Setting the Limits of Resectable Disease
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Gastric cancer: The times they are a-changin’
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Primary Tumor Resection and Survival in Patients with Stage IV Gastric Cancer
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“In this patient group, the OS rate is 3~5 months with best supportive care and 9~11 months with chemotherapy.(8) If there is human epidermal growth factor receptor-2 overexpression, trastuzumab can be added to the therapy, increasing the survival rate to 11~14 months.”
BackgroundCost‐Effectiveness Analysis of Second‐Line Chemotherapy Agents for Advanced Gastric Cancer
Lam, S. W., Wai, M., Lau, J. E., McNamara, M. J., Earl, M. A., & Udeh, B. L. (2016) · Pharmacotherapy The Journal of Human Pharmacology and Drug Therapy · doi:10.1002/phar.1870 · Cited by 22
“advanced or metastatic gastric cancer.(2) However, for those who fail first-line therapy, outcomes remain poor, with an estimated survival less than 6 months.”
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“1 3 reviews have reached a consensus to propose the ECF regimen as standard care [25].”
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“However, the majority of gastric cancer cases are diagnosed in the middle to late stage (6).”
BackgroundNew drug developments in metastatic gastric cancer
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“Although a recent metaanalysis showed combination therapy was better than monotherapy in terms of RR and OS [31], in our study, prolongation of PFS with the second-line combination over monotherapy was not translated into OS.”
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RetractedSynergistic antitumor effects of dasatinib and oxaliplatin in gastric cancer cells
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“[22] conducted a meta-analysis and reported a hazard ratio (HR) of 0.”
MethodKim, J. G., Sohn, S. K., Chae, Y. S., Song, H. S., Kwon, K.-Y., R, Y., Kim, M.-K., Lee, K. H., Hyun, M. S., Ryoo, H. M., et al. (2008) · British Journal of Cancer · doi:10.1038/sj.bjc.6604188 · Cited by 21
“However, in a recent meta-analysis of randomised phase II and phase III studies best survival results were achieved with three-drug regimens containing 5-FU, an anthracycline, and cisplatin in patients with advanced gastric cancer (Wagner et al, 2006).”
BackgroundPernot, S., Mitry, E., Samalin, E., Dahan, L., Dalban, C., Ychou, M., Seitz, J., Turki, H., Mazard, T., Zaanan, A., et al. (2013) · Gastric Cancer · doi:10.1007/s10120-013-0266-6 · Cited by 21
“of limited duration and tolerability varies according to the therapeutic protocol [1].”
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Ramucirumab: A New Therapy for Advanced Gastric Cancer
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“Chemotherapy is the primary modality for management of advanced and metastatic gastric cancers and has been shown to improve quality of life and prolong survival (Wagner et al., 2006).”
BackgroundYamaguchi, K., Fujitani, K., Nagashima, F., Omuro, Y., Machida, N., Nishina, T., Koue, T., Tsujimoto, M., Maeda, K., & Satoh, T. (2018) · Gastric Cancer · doi:10.1007/s10120-018-0811-4 · Cited by 21
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“analysis [16] have demonstrated the efficacy of each of these agent classes as first-line chemotherapy, to our knowledge this is the first study to simultaneously evaluate exposure to each agent class in all lines of treatment.”
BackgroundBeyond anticoagulant: Heparin as a potential anti-cancer agent
Lokwani, R., Azmi, N. S., Yusoff, M. M., & Ichwan, S. J. A. (2014) · Journal of Biochemistry Microbiology and Biotechnology · doi:10.54987/jobimb.v2i2.160 · Cited by 20
“inhibit the activity of βFGF [93-94].”
BackgroundGómez‐Ulloa, D., Amonkar, M. M., Kothari, S., Cheung, W. Y., Chau, I., Zalcberg, J. R., Suriñach, N. L., & Falcone, A. (2020) · BMC Gastroenterology · doi:10.1186/s12876-020-01232-z · Cited by 20
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“The majority of GC patients are diagnosed in the middle to late stage and therefore lose the opportunity to be cured [4].”
BackgroundZhang, X., Zhang, C., Hou, H., Zhang, Y., Jiang, P., Zhou, H., Wang, L., Zhou, N., & Zhang, X. (2023) · Translational Oncology · doi:10.1016/j.tranon.2023.101657 · Cited by 20
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“In advanced gastric cancers, the median overall survival is approximately 6 months [9].”
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“Thus, chemotherapy is still very important especially for patients with recurrence and metastasis [1].”
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“Data from randomised studies have shown that combination chemotherapy results in a significant survival advantage and improves quality of life in patients with advanced GC (Murad et al, 1993; Pyrhonen et al, 1995; Glimelius et al, 1997; Wagner et al, 2006).”
BackgroundAmarantidis, K., Xenidis, N., Chelis, L., Chamalidou, E., Dimopoulos, P., Michailidis, P., Tentes, A.-A. K., Deftereos, S. P., Karanikas, M., Karayiannakis, A. J., et al. (2011) · Oncology · doi:10.1159/000330199 · Cited by 20
“There is no globally accepted standard chemotherapy regimen for those patients; therefore, the need for more effective systemic therapy is urgent. Combination chemotherapy seems to be more advantageous than monotherapy [”
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“Unfortunately, there is no internationally accepted standard chemotherapy for advanced gastric cancer, and uncertainty remains regarding the choice of the optimal regimen (5,6).”
BackgroundRecent advances in chemotherapy for advanced gastric cancer
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Preoperative chemotherapy with S-1 and cisplatin for highly advanced gastric cancer.
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Targeted therapies in gastric cancer treatment: where we are and where we are going
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“In the advanced setting, a number of meta-analyses have clearly demonstrated the survival benefit associated with chemotherapy compared with supportive care alone and the superiority of combination chemotherapy over therapy with 5FU single agent [3, 4].”
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“Despite recent advances in the diagnosis and treatment of gastric cancer, the prognosis of individuals with an advanced stage of disease remains poor and treatment options mainly focus on surgery and chemoradiotherapy (Wagner et al. 2006).”
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“DLT was defined as any of the following adverse events occurring in the neoadjuvant chemotherapy period: (1) grade 4 neutropaenia lasting>4 days; (2) grade 4 thrombocytopaenia (<25×109/L); (3) febrile neutropaenia; (4) grade 3 or 4 non-haematological toxic effects; (5) a treatment delay longer than 14 days due to drug…”
BackgroundManagement of Metastatic Gastric Cancer
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AGAMENON study group, Carmona‐Bayonas, A., Jiménez‐Fonseca, P., Custodio, A., Cánovas, M. S., Hernández, R., Pericay, C., Echavarría, I., Lacalle, A., Visa, L., et al. (2017) · Gastric Cancer · doi:10.1007/s10120-017-0718-5 · Cited by 20
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Discoidin domain receptor 1 activity drives an aggressive phenotype in bladder cancer.
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BackgroundOptimising treatment regimens for the management of advanced gastric cancer
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BackgroundResultTargeting deficient DNA damage repair in gastric cancer
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Chemotherapy for Advanced Gastric Cancer
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“Gastric cancer is one of the most frequent causes of cancerrelated death worldwide [1,2].”
BackgroundTaxanes in the Treatment of Advanced Gastric Cancer
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“Efficacy rates of 50% have been reported for chemotherapy drugs, such as cisplatin (DDP), which are widely used in clinical settings [2, 3].”
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“Because the majority of patients with gastric cancer present with metastatic disease and nearly all patients develop chemotherapy resistance [22], our findings may contribute to improved control of gastric cancer patients.”
BackgroundTan, Y. C., Wang, H., Xu, B., Zhang, X., Zhu, G., Ge, Y., Lu, T., Gao, R., & Li, J. (2022) · Frontiers in Pharmacology · doi:10.3389/fphar.2022.977708 · Cited by 19
Metadata
- Authors
- Wagner, A. D., Grothe, W., Haerting, J., Kleber, G., Grothey, A., & Fleig, W. E.
- Affiliations
- From the First Department of Medicine, Coordinating Centre for Clinical Trials, Department of Medicine IV, and Institute of Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany; and Mayo Clinic College of Medicine, Rochester, MN
- Mayo Clinic (US)
- Venue
- Journal of Clinical Oncology
- Published
- 2006-06-20
- Volume
- 24
- Issue
- 18
- Pages
- 2903-2909
- ISSN
- 0732-183X (ISSN-L)
- 1527-7755
- OpenAlex
- W2145390243
- Cited by
- 1,171
- References
- 51
- Citations by year
- 2026: 7 · 2025: 15 · 2024: 26 · 2023: 28 · 2022: 34 · 2021: 64 · 2020: 55 · 2019: 54 · 2018: 69 · 2017: 89 · 2016: 72 · 2015: 84 · 2014: 105 · 2013: 92 · 2012: 77
- FWCI
- 9.54
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Clinical Oncology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- American Society of Clinical Oncology
- Bundesministerium für Bildung und Forschung (01GH0105)
- Topics
- Health Sciences › Medicine › Oncology › Gastric Cancer Management and Outcomes
- Health Sciences › Medicine › Oncology › Colorectal Cancer Treatments and Studies
- Health Sciences › Medicine › Surgery › Intraperitoneal and Appendiceal Malignancies
- Keywords
- advanced gastric cancer, first-line chemotherapy, 5-fluorouracil, cisplatin, anthracyclines, irinotecan, combination chemotherapy, overall survival, best supportive care, epirubicin, chemotherapy toxicity
- MeSH terms
- Antineoplastic Combined Chemotherapy Protocols, Humans, Stomach Neoplasms
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